Special Investigation Unit Lead Review Analyst II (Aetna SIU)

CVS Health•Work At Home-Florida, FL

7d•$43,888 - $85,068

About The Position

The Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research. The role evaluates provider, member, pharmacy, and ancillary healthcare billing patterns for signs of fraud, waste, abuse, and other anomalies, using internal claims data, analytical tools, business rule results, and industry intelligence to assess concerns and determine whether they warrant formal investigation. The analyst develops proactive and reactive leads; analyzes medical and pharmacy claims, billing and utilization trends, coding, reimbursement, and financial impacts; researches potential schemes and associated entities; and prepares evidence-based lead summaries and recommendations. The role collaborates with investigative, clinical, legal, compliance, and business partners, supports improvements to fraud detection and lead generation, and helps share knowledge about emerging schemes and healthcare billing practices. The position must comply with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures; maintain confidentiality; meet productivity, quality, and timeliness standards; and support audits, quality reviews, and regulatory reporting. Travel may be required up to 10%.

Requirements

At least 3 years of experience in healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud.
Strong analytical and critical-thinking skills, including the ability to identify trends and anomalies.
Experience interpreting large healthcare datasets and turning findings into actionable insights.
Working knowledge of healthcare claims processing and coding methodologies.
Ability to travel up to 10%.
Bachelor's degree or an equivalent combination of education and experience.

Nice To Haves

Experience in a healthcare payer Special Investigations Unit (SIU).
Knowledge of Medicare, Medicaid, Commercial, and Marketplace healthcare programs.
Understanding of medical and pharmacy claim data.
Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding structures.
Familiarity with healthcare payment methodologies and reimbursement models.
Experience using fraud detection tools, business rule engines, and investigative case management systems.
Experience with Tableau, Power BI, or equivalent analytical platforms.
Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification.
Excellent verbal, written, and presentation skills.
Strong organizational and time-management abilities, including the ability to manage multiple priorities.
Bilingual in English and Spanish.

Responsibilities

Develop proactive and reactive leads to identify potential fraud, waste, and abuse.
Generate FWA leads by mining claims databases, reporting tools, and investigative systems.
Validate and refine business-rule leads to assess credibility and investigative value.
Examine spike analyses, utilization trends, payment anomalies, and outlier reports for unusual billing patterns.
Evaluate provider, member, pharmacy, DME, transportation, and facility billing for indicators of fraud or abuse.
Monitor internal and external intelligence sources for emerging fraud schemes and patterns.
Perform quantitative and qualitative analysis of medical and pharmacy claims data.
Analyze CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends.
Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses.
Research using internal systems, public records, licensing boards, sanctions lists, and other investigative resources.
Analyze relationships among providers, members, facilities, and associated entities for potential schemes or collusive activity.
Prepare lead summaries describing allegations, supporting evidence, and risk indicators.
Present analytical findings and recommendations to SIU leadership and investigative staff.
Determine whether findings support formal investigation, monitoring, or closure.
Document investigative rationale and supporting evidence in accordance with SIU policies and regulatory requirements.
Provide actionable recommendations based on analytical findings and business intelligence.
Partner with investigators, clinicians, legal, compliance, and business partners on potential FWA concerns.
Participate in fraud trend discussions and special projects to strengthen fraud detection.
Support continuous improvement of business rules, data mining strategies, and lead-generation methodologies.
Assist with training and knowledge sharing related to emerging fraud schemes and healthcare billing practices.
Comply with applicable regulations, organizational policies, and SIU procedures; safeguard sensitive information.
Meet departmental productivity, quality, and timeliness standards and support audits, quality reviews, and regulatory reporting.